Applicable in Death cases only

No. FCI-DCPT/2017-18 Date:

The Manager (P&GS)

LIC of India
Delhi Divisional Office – 1,
Jeevan Prakash, 6th, 7th Floor,
25, K.G. Marg,
New Delhi – 110001.

Dear Sir,

Reg: Master Policy No. - NGSCA / 103004095 – Claim Papers.

Enclosed please find herewith the following documents for Annuity in favour of
Mr./Ms._____________________________________________________, Pension A/c No. _______________,
Beneficiary.

a) Form B - Letter to LIC

b) Form N – Letter of Authority
c) Application of Pension
d) Nomination Form
e) Two advance discharge receipts

Encls: As above

For and on behalf of

FCI Defined Contribution Pension Trust

(________________)
Authorised Signatory

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 Food Corporation of India-Defined Contribution Pension Trust
16-20, Barakhamba Lane, New Delhi – 110 001

FORM-B
(In Death Cases)

No. FCI-DCPT/2017-18 Date:

The Manager (P&GS),

L.I.C. of India,
P & GS Deptt., 6 & 7th Floor,
25, Kasturba Gandhi Marg,
New Delhi-1 l0001

Dear Sir,

Ref: Master Policy No. - NGSCA / 103004095.

1. We regret to advise that Mr. / Ms. ____________________________________, member died on

______________________. In accordance with the nomination dated _______ made by the Member and registered
in our books, the Beneficiary(ies) entitled to receive the benefits of the assurance on the life of the Member is / are:

Sl. Name of Address of Nominee Relation- Date of Proportion If Minor,

No. Nominee ship with Birth of by which name of the
Member Nominee Pension Guardian
will be
shared

2. A certified copy of Date of Birth of beneficiary is attached.

3. The said Beneficiary has selected the option to receive the benefit in the form of Annuity payable as per
option No…… and we have approved the said option for the Beneficiary. Accordingly the said Beneficiary is
entitled to receive Annuity, as per details mentioned in his / her application. The 1 st such installment falls due on
__________.

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4. We shall be passing to you, letters of authority to pay, on our behalf and as our agent, to the Beneficiaries of
deceased Members the pension payment shown against their names in such letters and we agree and declare that the
receipts signed by the said Beneficiary shall be sufficient, valid and legal discharge to you for the payment that may
be made by you from time to time in respect of such letters of authority.

5. We hereby agree that, if at any time you are called upon to make payment to the Govt. of India of any sums
towards Income Tax and any other taxes and duties in respect of the said Beneficiary in excess of the amounts
deducted by the Corporation on the basis of deductions advised by us in the said letters of authority for payments, we
shall reimburse the corporation such excess sums on receipts of the appropriate advice from them.

For & on behalf of

FCI Defined Contribution Pension Trust

(________________)
Authorised Signatory

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 Food Corporation of India-Defined Contribution Pension Trust
16-20, Barakhamba Lane, New Delhi – 110 001
FORM-N
(LETTER OF AUTHORITY FOR PAYMENT OF ANNUITY -DEATH CASES ONLY)

No. FCI-DCPT/2017-18 Date:

The Manager (P&GS),
LIC of India,
Delhi Divisional Oflice-1,
Jeevan Prakash, 6th & 7th Floor,
25, Kasturba Gandhi Marg,
New Delhi-110001
Dear Sir,

Ref: Master Policy No. NGSCA /103004095.

We do hereby direct, authorize & empower, ________________________, the Annuity Provider to pay
Annuity on our behalf and to Mr./ Ms ______________________, as beneficiary of the deceased member who died
on ___________, after deduction of Income Tax and other taxes & duties, particulars of which are given as under.
1. Membership No.

2. Name of beneficiary
3. Address of the beneficiary

4. Due date of pension

5. Amount of Pension
6. Income Tax/deductions, if any
7. Net amount payable
We hereby admit and acknowledge that the above mentioned payment which shall be made by you
shall be in full settlement of payments due to us and we hereby declare that receipts signed by the payee shall be
sufficient, valid and legal discharge to you for the respective payments made to him / her and shall be fully binding
on us as if the payments had been made to us and the receipts signed by us.
For & on behalf of
FCI Defined Contribution Pension Trust

(________________)
Authorised Signatory
(Signature of the Annuitant)

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 FOOD CORPORATION OF INDIA
(DEFINED CONTRIBUTION PENSION SCHEME)
APPLICATION FOR PENSION CLAIM ON DEATH OF MEMBER

1. Name
2. Employee No. :
3. CPF No. :
4. Pension Account No. :
5. Permanent Address :

6. Date of Appointment :
7. Date of entry into the Scheme :
8. Date of Death :
(Attach copy of Death Certificate, duly attested by Nominee / Beneficiary)
9. Date of Birth :
10. Details of Spouse / Beneficiary :
Sl. Name of Address of Relation- Date of Birth Proportion If Minor,
No. Nominee Nominee ship with of Nominee $ by which name of
Member Pension the
will be Guardian
shared

11. Option to choose Annuity Provider:

a. Life Insurance Corporation of India.

b. SBI Life Insurance Co. Ltd.
c. HDFC Standard Life Insurance Co. Ltd.
d. ICICI Prudential Life Insurance Co. Ltd.
e. Bajaj Allianz Life Insurance Co. Ltd.
f. Birla Sun Life Insurance Co. Ltd.
g. Star Union Dai-ichi Life Insurance Co. Ltd.
h. Reliance Life Insurance Co. Ltd.

12. Option to choose pension:

i) Annuity for life

ii) Annuity for life with return of Capital (ROC)
iii) Annuity for 5 years certain & Life thereafter
iv) Annuity for 10 years certain & Life thereafter
v) Annuity for 15 years certain & Life thereafter
vi) Annuity for 20 years certain & Life thereafter
vii) Annuity for life increasing at a simplest rate of 3% p.a.
viii) Annuity for life with a provision for 50% of the annuity payable to the spouse on death of the annuitant

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 ix) Annuity for life with a provision for 100% of the annuity payable to the spouse on death of the annuitant
x) Annuity for life with a provision for 100% of the annuity payable to the spouse on death of the annuitant
with return of purchase price on death of last annuitant
13. Mode of payment of pension: __________ (Monthly/Quarterly/Half-yearly/Yearly)

14. If you wish to transfer your annuity servicing to your nearest Divisional Office of Annuity Provider please
specify the area : ________________________________

Encls: 1. D.O.B Certificate of Nominee

2. ECS Mandate form
(Signature of Member)

To be completed by A/Cs / Pay Roll

15. Remittance particulars after last schedule i.e. as on 31st March of the Preceding Year)
Year Employer Share of Employee Share of
Contribution Contribution
Month

April

May

June

July

August

September

October

November

December

January

February

March

Manager / Asstt. Genl. Manager (Bills)

The particulars at Sl. No. 1 to 9 have been verified at our end and we certify that these are correct.

Asstt. General Manager (Pers.)

Distribution:-
1. Secretary, FCI-Defined Contribution Pension Scheme Trust, FCI, Headquarters, New Delhi.
2. Personal File of the Member.

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 FOOD CORPORATION OF INDIA
(DEFINED CONTRIBUTION PENSION SCHEME)
NOMINATION FORM

1. Name of the employee -----------------------------------------------------

2. Father’s / Husband’s Name -----------------------------------------------------
3. Designation -----------------------------------------------------
4. Name of the office/ Place of posting ------------------------------------------------------
5. Gender ------------------------------------------------------
6. Staff Code No. ------------------------------------------------------
7. Employee No. -----------------------------------------------------
8. Permanent Account No.(PAN) -----------------------------------------------------
9. Aadhaar Number: ------------------------------------------------------
10. Date of Birth ------------------------------------------------------
11. Date of joining FCI ------------------------------------------------------
12. Date of Superannuation ------------------------------------------------------
13. Permanent address with Pin Code ------------------------------------------------------
------------------------------------------------------
14. Address for communication / Present address-----------------------------------------------------
----------------------------------------------------
15. Mobile number ----------------------------------------------------
16. E-mail ID ----------------------------------------------------
17. Details of Nominee(s)
Sl. Name Age Relationship %age If Minor, name of the
No. with Employee of Guardian
share

(Signature of the employee)

Date:-__________________
____________________________________________________________________________
DECLARATION BY WITNESS
Name and Address of the Witness Signature of the Witness

1. ____________________________________
____________________________________ ___________
2. ____________________________________
____________________________________ ___________

(To be filled by the controlling unit office)

Verified and countersigned by the controlling office.

Name:
Designation:
Date:
________________________________________________________________________
Controlling Office to forward the nomination to:
1. The Secretary, FCI-DCP Trust, FCI, Headquarters. (2 Copies).
2. The Assistant General Manager (Bills),FCI, Zonal Office
3. Personal File of the Employee.

Page 7 of 9
 Food Corporation of India-Defined Contribution Pension Trust
16-20, Barakhamba Lane, New Delhi – 110 001
(Applicable in Death cases only)

(To be filled in Duplicate)

DISCHARGE RECEIPT

Received a sum of ___________ (Rupees_______________________________

____________________________________________________________________ only) from Food Corporation
of India in full and final Settlement on behalf of Late _________________________ Employee
No. __________________ under Master Policy No. - NGSCA / 103004095 expired on _________.

Date: Rs.1/-
Revenue
Place: Stamp

Signature of the Beneficiary across Revenue stamp

Name of the Beneficiary: _____________________________

WITNESS:

SIGNATURE___________________________

NAME ________________________________

ADDRESS _____________________________
____________________________________
___________________________________

(_________________)
Authorised Signatory
Food Corporation of India-Defined Contribution Pension Trust,
16-20, Barakhamba Lane,
New Delhi-110001.

Page 8 of 9
 ECS Mandate Form

Bank Authorization Letter

I, ……………………………………..…………………… Son/Daughter/Wife of
……………………………………………………, would like to receive the sums paid by LIC under Policy
No. NGSCA / 103004095 to me electronically in my Bank account, the details of which are as under:
Payee’s Particulars

Name of Payee as in Bank Account

Policy No. NGSCA / 103004095
* Pan Card No.
Permanent Address of the Member

District
Pin code
State
Telephone Number with STD Code
Mobile No.

Email Address

Bank Details

Name of Bank

Bank Branch (Full Address)

**Bank Account No.

IFSC Code

Encls: 1. * Photo copy of Pan Card duly self attested by Beneficiary.

2. ** Cancelled cheque and copy of Passbook.
(If cheque facility is not available, kindly get the above authorization letter attested from concerned Bank).

Signature ___________________
Name of Member ___________________
Emp. Code ___________________

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